DOC request three complete - Cannabis Defense Coalition

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Jan. 23. 2009 11 :49AM CBR Medical Inc. No.3192 P. 3/6
OFI'ENOCR I.ll nATA'
STATE OF WI'SHINGl·ON
DEPARTnOENT OF CORRECTIONS
Medicinal Use of Marijuana Verification
To be filled out by Prescriber:
Dear Prescriber.
l3y state statute the Washington State Department of Corrections is charged with the responsibility to supervise some
offenders after they have been convicted of a felony. The above named patient is currently under sl,lpervision by the
Department. Supervision is designed to help the offender avoid those environrnents or situations that lead to their criminal
behavior. Often illi~it drug LIse is a contributing factor in an individual's Criminality. Accordingly it's usual that thei courtor
the Departmerit of Corrections will impose a condition of supervision that the offender not LIse. or possess iUicit drugs,
including marijuana. This offender has claimed that they have a condition for which the medicinal use of marijuana has
been recommended. The below verification is to determine the legitimacy of their claim. Thank you in advance for your
assistance. If you have questions please feel tree to personally contact the Medical Director of the Oepartmef]t at (360)
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1. Is this patienl under your car~ 1L:1Yes UNo /""
2.
3
Are you recommending medical marijuana for his patient due to a diagnosis of AcqLlired
Immunodeficiency Syndrome (AIDS)
a. If the answer to question 2 is "Yes", does he/she have anorexia
b. . If the answer to question 2a is ,"Yes', does he/she have weight loss
DYes
Are you recommending medical marijilana for this patient due to nausea and vomiting
DYes
associated with cancer chemotherC!PY
8. If the answer to quastion 3 is "Yes",·has the patIent failed to respond to conventional
antiemetic treatments .
b. If the answer to question 3a is "Yes", please describe what those treatments were (medication, dose,
duration): \ t\....... .
N ...),;. \'\ fr \ \ V:.. \.'\ t-
c. What is the planned schedule of chemotl1r;rapy
~ ,.. iy (;:\ fr\; ll:.1 \-l.
I.~
ElTes-a-No
Q-.¥es-~.'--B~No
...
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4.
If you answered "No" to items 2 & 3 above, what is tile reaSOn you are recommending. medicinal use of
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marijuana j' "\ \ \ .... . . . I,. ( ..... , '> J\J\I \....
ec~ .t~","t\........ \-I\!..':: C.l3R. -.f""'''1('~''..",..,,, "---" ........